Encyclopedia of

Insomnia

Photo by: Alex Bramwell

Definition

Insomnia is a condition that occurs when a person in unable to get long
enough or refreshing enough sleep at night. Insomnia can result from an
inability to fall asleep, an inability to stay asleep, or waking too early
before having gotten enough sleep.

Description

Insomnia is a disorder in which people are unable to get enough, or enough
restorative, sleep because of one or more factors. People with insomnia
often have daytime symptoms related to a lack of sleep, such as daytime
sleepiness,
fatigue
, and decreased mental clarity.

There are two main types of insomnia. One is acute insomnia (sometimes
called transient insomnia). This type occurs when insomnia symptoms exist
over a reasonably short period of time. The other type is chronic
insomnia, which is diagnosed when the symptoms manifest themselves over a
longer period (generally more than one month). Insomnia can also be
classified as either primary or secondary. Primary insomnia is a disorder
that cannot be attributed to another condition or disorder. Secondary
insomnia can be traced back to a source, which may be a medical condition;
the use of medications, alcohol, or other substances; or a mental disorder
such as severe depression.

Not all disruptions in the normal pattern of sleeping and waking are
considered insomnia. Such factors as jet lag, unusually high levels of
stress
, changing work shifts, or other drastic changes in the person's routine
can all lead to sleep problems. Unless the problems are ongoing and severe
enough that they are causing distress for the person in important areas of
life, he or she is not considered to have insomnia.

Causes and symptoms

The symptoms of insomnia can vary greatly from person to person. Some
people find that they have trouble falling asleep at night and can lie in
bed for hours without being able to drift off. Others find that they fall
asleep easily but wake many times during the night. Other people awaken
too early in the morning and are then unable to get back to sleep. Some
people even get enough hours of sleep but find that they do not feel
rested, often because their sleep is too light.

Not all people experiencing insomnia have symptoms that occur during the
daytime, but many do. Some people experience such symptoms as reduced
ability to concentrate or pay attention, decreased alertness, and mental
sluggishness. Some people have trouble staying awake. More people think
that they have this symptom than actually do. Upon clinical examination
many people who think that they are excessively sleepy during the day
actually are not.

Many different things are thought to cause or contribute to insomnia. Such
stressors as starting a new job or changes in routine, such as beginning
to work a different shift, can lead to temporary sleep problems. Sleep
problems can become aggravated, and persist after the worry or change
causing the sleep problem has been resolved. This persistence is thought
to be related to the anxiety created by attempting to go to sleep and not
expecting to fall asleep. Anxiety about sleep loss can lead to a vicious
circle in which the person has more and more concern about being able to
fall asleep, making it ever increasingly difficult to do so. Some people
even report that they are better able to fall asleep when they are not in
their beds. This relative success is thought to occur because the new
environment is not associated with the fear and anxiety of not being able
to sleep, therefore making it easier to fall asleep.

Many other factors are thought to lead to or perpetuate insomnia. These
include drinking tea or coffee, eating a large meal, taking certain
medications or drugs of abuse (cocaine,
amphetamines
) that have a stimulating effect, or exercising heavily in the hours
before attempting to sleep. Also, attempting to sleep in a room with too
much light or noise can make it harder for some people to sleep. Doing
activities in bed that are not associated with sleep, such as reading or
watching television, can make it more difficult for some people to fall
asleep when they finally want to. Sleep may be even more difficult if the
television show or book was frightening or upsetting.

Demographics

There are many different opinions about how much of the general American
population experiences insomnia. Estimates suggest that around 5–20%
of the adult population suffers from some form of insomnia or long-term
sleeping problems. Nearly half report at least occasional sleeping
problems. Accurate data is difficult to gather, as many people misperceive
how much sleep they actually get and how many times they normally wake up
during the night. It is generally agreed, however, that women are more
likely than men to suffer from insomnia. As people get older, they are
also are more likely to experience insomnia. People who are nervous or
tense are more likely to have insomnia than those who are not. Lastly,
people who live near airports or other sources of nighttime as well as
daytime noise have higher rates of insomnia than the general population.

Diagnosis

According to the
Diagnostic and Statistical Manual of Mental Disorders
(
DSM-IV-TR
), which presents the guidelines used by the American Psychiatric
Association for
diagnosis
of disorders, in order to be diagnosed with primary insomnia, a person
must experience the symptoms for at least a month, and the symptoms must
cause them distress or reduce their ability to function successfully. The
symptoms cannot be caused by a different sleep disorder, a medical
condition, or be a side effect of medications or substance abuse.

Insomnia may also be comorbid with (occur together with) other psychiatric
disorders, including mania, depression, and the anxiety disorders.

Insomnia is a disorder that is usually self-reported; that is, patients
usually bring up the subject of sleep
problems with their doctors rather than the doctor suggesting the
diagnosis. There are no laboratory tests for insomnia, but the doctor may
suggest keeping a sleep diary, in which the patient notes the time they
went to bed, the time(s) at which they got up during the night, their
activities before bed, etc. Sleep diaries can be helpful in uncovering
specific factors related to the insomnia.

Treatments

Many treatments have been explored for treating insomnia, in a number of
different settings. The patient may wish to consider consulting a sleep
clinic or a doctor who specializes in the treatment of
sleep disorders
as well as their family doctor.

Behavioral and educational therapies are usually tried first, because they
do not have side effects and cannot create a chemical dependence the way
some sleep medications can. Many different approaches have been designed
to help patients whose insomnia is linked to particular factors.

Behavioral treatments

One common behavioral therapy involves changing any pre-bedtime activities
or behaviors that might interfere with sleep. Avoiding large meals,
alcohol or caffeinated beverages, or intensive exercise in the hours
before bedtime may help the patient to fall asleep.

Another non-medicinal treatment for insomnia involves controlling the
patient's mental associations with the bedroom. The patient is trained to
associate the bed only with sleep, not with the frustration of trying to
fall asleep or with such waking activities as reading or watching
television. As part of this training, if the patient cannot sleep after a
certain amount of time, he or she is instructed to get out of bed and
spend time somewhere else in the house doing an activity that they find
relaxing. The patient lies down again only when sleepy. This technique
helps to prevent frustration from trying to sleep.

Another common technique that does not involve medication is sleep
restriction therapy. During this therapy, the amount of time that patients
are allowed to spend in bed is limited to only slightly more time than
they believe that they already sleep at night. Gradually the amount of
time patients are allowed to spend in bed is increased until they are
getting a full night's sleep. Unfortunately, many people find this
treatment difficult to stick with, because they often become mildly
sleep-deprived. The resultant fatigue can be useful, however, as

People with insomnia do not get enough restorative sleep, and often
have daytime symptoms such as daytime sleepiness, fatigue, and
decreased mental clarity.

(Photo by David Pollack. Corbis Stock Market. Reproduced by
permission.)

it may help them fall asleep more easily and to stay asleep longer at
night.

Teaching relaxation and the ability to concentrate on relaxing thoughts or
images can also help patients experiencing insomnia. Most of these
therapies also include setting times for waking and having the patient
stick to them even if he or she has not gotten a full night of sleep. The
elimination of all daytime napping can help to facilitate sleep at night.
These treatments are effective by themselves but may also be combined with
other approaches. The course of treatment depends on the patient's
specific symptoms.

Treatment with medications

Many different medicines, which are called hypnotics, are used to treat
insomnia. These are usually not recommended for use for longer than a week
because they may cause dependence. In addition, there is always the risk
of side effects. There are many different types of hypnotics, and choosing
one for a patient depends on the patient's symptoms, other drugs that he
or she may be taking, any medical or psychological conditions, and
other health factors. Medication treatment is best used in coordination
with a behavioral therapy program.

Alternative remedies

Alternative remedies for insomnia, particularly herbal preparations,
should be mentioned because they are among the most popular
nonprescription treatments for sleep problems. According to
Prevention
magazine, insomnia is the sixth most common condition treated with herbal
formulas in the United States; it accounts for 18% of all use of herbal
preparations. Some herbs used for insomnia are safer than others. Persons
who are using alternative remedies, whether to treat insomnia or other
conditions,
should always tell their doctor what they are taking, how much, and how
often
. This warning is important because some herbal preparations that are safe
in themselves can interact with prescription medications.

Prognosis

Untreated insomnia has potentially serious consequences, including an
increased risk of motor vehicle accidents, impaired school or job
performance, and a high rate of absenteeism from work. Fortunately,
insomnia can be treated very effectively in most patients. Treatment using
a combination of approaches is usually most effective. Patients who have
had insomnia once are at an increased risk for recurrent insomnia.